While scientific evidence, in theory, plays a crucial role in predicting issues that influence the health care policy agenda, its role, in reality, does not always reflect this. Sutherland, et al. (2012) asserted that science and public policy makers have always gone hand in hand, the significance of one to the other has always been acknowledged but in recent times there has been an evolving discussion on how to optimally achieve this. This has continued to the point where ‘evidence-based policy’ is highlighted as the standard to which democracies should aspire. This, in turn, has established a platform for scientists, working in both the natural and social fields, to work collaboratively with various specialists in processes related to policy-making (Sutherland, et al., 2012).
An example of this was seen in the previous government administration of the United States (hereafter U.S.), where the U.S. government utilised the expertise of scientists as advisors who actively served on the President’s Council of Science and Technology. However, while this relationship is beneficial, it is not without its dissenters as some aspects of recent health care science have created controversy on the basis that these scientific facts represent divergent views from religious and other beliefs. Another example of how the political agenda usurps scientific evidence occurred in the U.S., during the presidency of George W. Bush. His administration curtailed stem-cell research because the research involved testing on aborted fetuses, which went against President Bush’s religious beliefs.
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Religiosity is not the only other factor influencing the policy agenda. Based on evidence from the U.S., partisan politics also affects health care policy. This was demonstrated in the passing of the Affordable Care Act (ACA). Some observers would not be of the view that the ACA was partisan in nature, since a Republican, Mitt Romney, created it in Massachusetts, and a Democrat President, Barack Obama, got it passed through congress making it federal law. However, the Trump administration has taken steps to repeal the ACA even without an alternative plan. From this, it is lucid that the ensuing conundrum about the ACA is partisan in the way that it has been treated with by politicians, even though people of the U.S. from both political parties benefit from the ACA’s policies. This is very disheartening because health care should be non-partisan as it concerns the life and welfare of human beings.
The World Health Organization (WHO) (2019) stated that policies once developed might change over time as a result of multiple pressures. Whenever the environment becomes unstable, then the dynamic surrounding the policy shifts and changes are accelerated. This can result in previous policy decisions, which were beneficial being reverted. Then as the crisis evolves, the guiding framework for that policy dissolves. One could argue that, if Senator John McCain had not notoriously shown the thumbs down sign as Republicans attempted to rescind the ACA in the early days of the Trump administration then possibly the U.S. would have faced an even greater debacle regarding its health policy, subsequent to this vote. This unfortunately reveals how health care policy is arrived at, at least in the U.S., and clearly it is not related to any science, except political science.
This further illustrates that while scientific evidence might be among the most important factors predicting the issues that get onto the policy agenda, it is often, second or third tier and there is no guarantee that if these issues do get on the policy agenda that they will remain there.
The literature indicates that government action more times than not does reflect the interests of the most powerful groups. I support this perspective. A study conducted by Gilens and Page (2014) indicated that elites in the economy, business interests and organised groups have a significant impact on U.S. government policy. What powerful groups lack in numbers they make up for in money and within political circles, funding speaks volumes. Rennie (2016) stated that as a result of an ideological shift in the 1970s, this heralded a re-evaluation of how corporations saw themselves as part of civic society. Eventually, the notion of special interest replaced that of civic duty and the public sector became fair game.
An example of how special interest groups have influenced politics in the U.S. is reflected in the National Rifle Association’s (NRA) ability to wield power over Congress because they provide campaign funds. As a result of this, liberal and conservative congressional members alike circumvent or vote against gun control policies despite the fact that the Centre for Disease Control (CDC) and other key health care organizations have repeatedly identified gun violence as a public health threat. This arrangement exists because in order to be re-elected, there must be an availability of funds. To access these funds, politicians realise that they must acquiesce to the requests of certain groups who hold the moneybag for their campaigns. This translates into politicians advocating for the interests of the few and this is what eventually sets the agenda for policy discussions.
The overarching agenda of the government is often informed by the campaign’s agenda. The candidate promotes his/her agenda on the basis or hope that the majority in fact wants what s/he is promising to deliver. This agenda is then framed by problems and alternative solutions that gain or lose the attention of the public. The foregoing forms the basis of majoritarian electoral democracy. However, the majoritarian electoral theory does not account for variables relating to wealthy persons and special interest groups. William Domhoff (cited by Gilen & Page, 2014) offered insight into how high power groups and people work through charities, think-tanks, and opinion influencing machinery and politicians to set the agenda for key issues that dominate policy making notwithstanding the democratic election process.
Since not all of the problems that face a country can be addressed, there is intense competition for responsiveness to a particular group’s agenda. Groups must also compete to earn their spot on the agenda. Birkland (2007) opined that as issues come to the forefront, there are many approaches and in order to keep the issue on the agenda, these groups must continuously reiterate them so that they are actively considered. If that particular approach to a problem prevails in a policy debate, then the issue/group will get the attention it desires. If these groups already have a powerful congressional member championing their cause, then it is possible to make great inroads even if the majority disagrees with the policy proposed.
Taken together, from the discussion above, one can see how special interest groups provide a fundamental link between the government and what ultimately gets on the agenda. These groups however, are further connected to the economy and may be a powerful non-majority force behind the scenes that wield political influence in their favour.
In recent years there have been both enabling factors in the redistribution of health care resources, as well as, factors that have restrained this. Enabling factors are illustrated in the move by over twenty countries to establish social health insurance to increase health funding with the intent to extend this coverage to entire populations, and in so doing provide health care at an affordable cost for all (Carrin & James, 2005). In Canada for example, over CAD$50 billion was given to various provinces to assist with hospitals, health care costs, prescriptions and doctor-patient care (Wolfson, 2018). This is supported by a commitment of 40% of Canada’s fiscal budget towards health care. However, health care costs for countries like Canada have begun to increase in comparison to GDP and this has created challenges for advancing health care redistribution (Stabile, 2011).
In some countries, bold moves in the right direction have now become hindered by failure to commit financial resources to support health care redistribution (Maeda et al., 2014). This is perhaps the most significant reason that resources cannot be redistributed to where they are needed. It is always money that dictates who gets what. Additionally, while there have been many new technological advances in medicine, it is often the case that these do not reach the majority who could benefit from them. This is because there is no active allocation of funds for creating access to these technologies to those in resource-poor communities, seniors, or the aged with limited education, and consumers in regions with limited access to the internet and other digital technologies. Nambisan and Nambisan (2017) have stated that health care organisations then began to bear the brunt of the burden and had to create novel and proactive strategies to help create equity in the allocation of benefits. However, this is easier said than done.
Another restraint related to the financing of health care and its redistribution, which causes people at the community level, in remote areas and of underserved populations to be unable to access health care, is that health care providers might be reluctant to open practices where they can get access. Practitioners may not want to provide medical services in remote areas because the population wouldn’t be able to financially support it. Underfunding from the government further restricts this. Furthermore, in those areas where underserved populations frequent, there may also be a dearth of health care facilities because of said lack of funding compounded by lack of security and low interest from the state and federal governments.
Competing issues on the policy agenda add further pressure to the situation. The aforementioned attempt to repeal the ACA by the current U.S. government administration is one such issue. Before the ACA was stripped of many of its features, the health care plans were more affordable, and more Americans could afford health care insurance. However, since the current administration, much of the benefits have been rescinded and the high deductible and premium costs are not affordable for even some middle class Americans. This repeal is being pursued, despite the law’s success because a powerful few do not want the ACA to be the overarching health care policy in the U.S. Critics of the repeal have suggested that a part of the underlying cause for the repeal is racism and dislike for former U.S. President, Barack Obama. Another example, was when politicians did not commit funding to support HIV/AIDS social programs, which made the HIV/AIDS epidemic worse, in part, because many people including politicians shunned the LGBT community when they could and should have allocated funds that could have helped to lessen the impact of the disease at a time when it was on the rise.
Other factors that have hindered the restructuring of health care are uneven allocation of power, social, economic, environmental and structural disproportions. These are considerations that come into play because power and resource distribution are dissimilar along lines of race, gender, social class, sexual inclination, gender expression, and other dimensions of individual and group identity (National Academies of Sciences, Engineering, and Medicine, 2017). This is especially the case because much of these groups have only recently gained acknowledgement or are still battling for equality and have little power in the longstanding institutions of government, which at times rejects the equality that members of these groups have attained, such as same-sex marriage.
In proposing solutions to enable health care redistribution, the best way to overcome the politics of health care is that the government needs to assume a greater role in providing finance for health care services. This may require an increase in the taxes people pay but it would perhaps still work out less to the amount some people pay for a year’s worth of insurance in premiums or insurance deductibles in the existing system.
In the case of the U.S., more is spent in health care dollars per person than any other country in the world, and yet their ranking in the provision of health services is very low (OECD, 2018). Perhaps it is the structure of the health care policy that is the issue. In light of this, many people believe that health care in the United States must be re-organised if everyone is to be able to access health care; as it is an inalienable right guaranteed in the Constitution. De Klerk and Salazar (2018) stated that health care policy simply does not cater to many people because they cannot afford it. Rather the system is a microcosm of societal inequalities with high-deductible, high co-pay plans that have become the usual in the provision of health care. This is evident in 29% of patients who reported that they did not seek health care because the cost was prohibitive (De Klerk & Salazar, 2018).
Nambisan and Nambisan (2017) suggest that informing people about how they can access existing health care facilities is part of the solution. They also advocate for health care organizations promoting innovation by allowing research to be carried out at their facilities. This would allow some people to experience new technologies. However, while these ideas are useful if the population that often has limited access is willing to pay for the services or, if there is a social service willing to pay for them, this is not always the case.
In summary, the main factor enabling health care redistribution is financing, in that there has been greater commitment by some governments to spend substantial amounts on health care. This has been further supported by the provision of social health insurance in some countries. Ironically, while financing enables this process, it is also the main factor hindering health care redistribution in countries where enough funds are not committed to the poorest and sickest of the population or where health care policies exclude such communities. Health care practitioners who are perhaps unwilling to establish practices in underserved populations and vulnerable communities because of the personal, financial and security risks involved further compound this issue. This therefore, stymies the move to reorient health care delivery toward chronic disease prevention and management, while key health services remain inaccessible at the community level.
References
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